Provider Demographics
NPI:1245842335
Name:BANNISTER, ALAN (MA SLP-CCC)
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:
Last Name:BANNISTER
Suffix:
Gender:M
Credentials:MA SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2419 19TH ST APT 2
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11102-3442
Mailing Address - Country:US
Mailing Address - Phone:614-843-1082
Mailing Address - Fax:
Practice Address - Street 1:2419 19TH ST APT 2
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11102-3442
Practice Address - Country:US
Practice Address - Phone:614-843-1082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-19
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029461235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist